The
rating should be based on a clinical interview
moving from broadly phrased questions about
symptoms to more detailed ones which allow a
precise rating of severity. The rater must decide
whether the rating lies on the defined scale steps
(0, 2, 4, 6) or between them (1, 3, 5) and then
report the appropriate number. The items should be
rated with regards to the state of the patient over
the past week.

2
- REPORTED SADNESS - Representing reports of
depressed mood, regardless of whether it is
reflected in appearance or not. Includes low
spirits, despondency or the feeling of being beyond
help and without hope. Rate according to intensity,
duration and the extent to which the mood is
reported to be influenced by events.

0

Occasional
sadness in keeping with the
circumstances.

1

2

Sad
or low but brightens up without
difficulty.

3

4

Pervasive
feelings of sadness or gloominess. The mood is
still influenced by external circumstances.

Difficulties
in starting simple routine activities, which are
carried out with effort.

5

6

Complete
lassitude. Unable to do anything without help.

8
- INABILITY TO FEEL - Representing the
subjective experience of reduced interest in the
surroundings, or activities that normally give
pleasure.The ability to react with adequate emotion
to circumstances or people is
reduced.

0

Normal
interest in the surroundings and in other
people.

1

2

Reduced
ability to enjoy usual interests.

3

4

Loss
of interest in the surroundings. Loss of feelings
for friends and acquaintances.

5

6

The
experience of being emotionally paralyzed,
inability to feel anger, grief or pleasure and a
complete or even painful failure to feel for close
relatives and friends.

Persistent
self-accusations, or definite but still rational
ideas of guilt or sin. Increasingly pessimistic
about the future.

5

6

Delusions
of ruin, remorse and unredeemable sin.
Self-accusations which are absurd and
unshakable.

10
- SUICIDAL THOUGHTS - Representing the
feeling that life is not worth living, that a
natural death would be welcome, suicidal thoughts,
and preparations for suicide. Suicidal attempts
should not in themselves influence the
rating.

0

Enjoys
life or takes it as it comes.

1

2

Weary
of life. Only fleeting suicidal
thoughts.

3

4

Probably
better off dead. Suicidal thoughts are common, and
suicide is considered as a possible solution, but
without specific plans or intention.

5

6

Explicit
plans for suicide when there is an opportunity.
Active preparations for suicide.